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Osteoporosis Risks

CE / CME

What I Learned From Patients About Chronic Conditions: Lessons in Osteoporosis

Physicians: Maximum of 0.25 AMA PRA Category 1 Credit™

Nurses: 0.25 Nursing contact hour

Released: May 24, 2021

Expiration: May 23, 2022

Nelson Watts
Nelson Watts, MD
CME/CE Information

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Primary care providers have an essential role in preventing and treating osteoporotic fractures. Below, I share may answers to several important questions on primary care management of osteoporosis posed by an audience of healthcare professionals during a live CCO webinar.

How does the patient’s motivation factor into osteoporosis treatment decisions?
A major challenge with managing chronic diseases—whether osteoporosis, hypertension, or hypercholesterolemia—is a lack of adherence to recommended medications. And as healthcare professionals, we have a key role in either helping or hindering this adherence.

For example, when a patient is starting a program of osteoporosis management, just leaving a phone message that a prescription has been called in is usually not the best way to engage the patient in his/her own care. It is better to approach this as a long-term project and to devote a face-to-face visit to medication adherence while involving the patient in shared decision-making around his/her management.

I can think of 2 illustrative examples. I once saw a returning patient who was clearly following a restricted diet—a major lifestyle change that I had been skeptical he would undertake. I asked him, “Did you have any trouble following the diet?”

His response was eye-opening. “No,” he said. “I had trouble deciding to follow the diet. Once I made that decision, I knew exactly what I needed to do.”

Another example involves a returning patient who was finishing 2 years of daily injections of a bone-building drug for osteoporosis.

“I have a confession to make,” she told me. “Before my first appointment with you, I made up my mind that I wasn’t going to do anything you suggested. I was just coming to get my family doctor off my case.”

That surprised me—by this point, she had been giving herself daily injections for 2 years.

“Something clearly changed your mind on that,” I said.

She responded, “Yes. You told me a fracture could be a life-changing event. I am happy with my life as it is. I went home and thought about the ways it might change for the worse if I had a fracture, and I realized I needed to do what you recommended.”

Why is there sometimes a big difference in T-scores for hip and spine?
When we see a difference between hip and spine T-scores, we call this a discordance. I explain to patients that the fact that we have a name for it means we are not surprised when we see it, but we do not currently have an explanation for it. There are some people who have a low T-score in the hip but not as low in the spine and vice-versa.

Sometimes I see a patient who has normal T-scores in the spine and hip but a low T-score in the forearm.

Technically, that is osteoporosis, but I would not prescribe medication for it. Here is why:

  • Our medications reduce the risk of spine fracture by approximately 70%, so if a patient’s T-score is low in the spine, I do recommend treatment.
  • Our medications reduce the risk of hip fracture (with more serious consequences) by approximately 40%, so if a patient’s T-score is low in the hip, I also recommend treatment.
  • Our medications reduce the risk of nonvertebral fracture by approximately 20%, and that includes hip fracture, so they must reduce the risk of nonvertebral, nonhip fracture by <20%. If patients’ T-scores are low in the arm only (and not in the hip or spine), they might get an arm fracture but are likely not at increased risk for hip or spine fractures. I would probably not recommend medication if that were the only issue.

Would you use testosterone to prevent or treat osteoporosis in men?
Testosterone is not generally recommended for osteoporosis management.

When I was chair of an Endocrine Society task force on osteoporosis guidelines in men, one of the task force members did not even want to measure testosterone in men with osteoporosis, much less offer it as treatment.

He did agree that you could use testosterone in men who are hypogonadal by repeated measures, who have organic hypogonadism, and who have symptoms of gonadal insufficiency. But in men with osteoporosis at high risk for fracture, we have no evidence that testosterone reduces fracture risk.

Four of the medications that have been shown to reduce the risk of fractures in women—alendronate, risedronate, zoledronate, and denosumab—are also indicated for osteoporosis in men. Zoledronate also has evidence from a large, 24-month randomized phase III trial that showed fracture reduction in men.

So, in a man with osteoporosis at high risk for fracture, even if testosterone is being considered for management of hypogonadism, I would recommend one of those 4 fracture-reducing medications to mitigate his fracture risk.

Your Thoughts?
What questions do you have about managing fracture risk in your patients? Please answer the poll and post your thoughts and questions in the discussion box.

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